I'm an American expat currently living in Turin, Italy. The headlines about COVID-19's spread in Italy are pretty scary. I put this notebook together so family, friends, and curious people can get a little insight into what's actually happening.
The first section offers a statistical overview. I'll update this every day. The second section has some of my anecdotal observations and tracks a few headlines. The third section has a little bit more on the importance of evidence-based storytelling.
Overview of the Problem
I'm pulling data from Italy's Civil Protection Department. I think they are doing a great job of providing the public with accurate information. Here are the latest figures from Piedmont. The total cases are the total number of diagnosed cases of COVID-19 in the region.
Turin is the regional seat of Piedmont. It's a quirky city of modest size situated at the foot of he Alps. The city hosts about 875,000 residents while an additional 3 million people live in the surrounding region of Piedmont.
Here are the total number of COVID cases in Piedmont starting from February 24th. Rollover the bars for more detailed information.
name='Total Cases in Piedmont (Turin)', marker_color=piemonte_color)
It's hard to understand the scope of the problem in any Italian province without comparing it against the epicenter of the original outbreak, Lombardy. Lombardy is just east of Piedmont. Both Lombardy and its capital Milan are much more populous regions. Here is the comparative growth of the virus in raw numbers.
Looking at the data on a logarithmic scale makes it easier to see the relative change over time. The important takeaway is the shape of each slope. I'm particularly interested in the slope's change after March 8th, the date of the original ban on regional movement, as compared to the slope after October 7th, the first significant governmental restriction from Rome in many months. Both dates are indicated by a red dot.
A slowing of the growth rates outside of Lombardy gave credibility to Prime Minister Giuseppe Conte's decision to order the original lockdown.
Testing is an important part of containing the virus' transmission. Roughly a quarter of Piedmont's residents have been tested by the start of the second wave. Better vigilance will hopefully help curb the infection rate faster.
mode='lines', name='Total Cases in Piedmont (Turin)',
mode='lines', name='Total Tested in Piedmont (Turin)',
mode='lines', name='Total Deaths in Piedmont (Turin)',
I am preparing to travel to the United States in the coming weeks. The route to and from the European Union is peppered with uncertainty and health risks. The Western world is spiking in cases and new restrictions are being announced weekly. Here is how I'm preparing for each leg of the trip.
First, I'm overdue for buying a comfortable washable/reusable mask. The 27/October entry in this notebook details the latest data on this type of mask. The packaging should display a CE mark or the validation of the Higher Institute of Health (often indicated as "EN 14683"). These masks will offer a filtering capacity (i.e. protection from others) of either 95% (type I) to 98% (type II).
The benefit of an additional layer of protection in the form of glasses remains unclear.
blockquote not implemented
The New York Times acknowledges that this is a compelling statement, but warns there are many vectors for uncertainty. The article concludes:
blockquote not implemented
🚎 🛫 Vanchiglia, Turin → Airport 🇮🇹 → Airport 🇺🇸
Readers of this notebook can clearly see that the COVID outbreak is currently quite bad in both Piedmont (Turin) and Lombardy (Milan) - the locations of my two main airports.
I was originally planning a direct flight from Malpensa (MXP) outside of Milan. But recent restrictions on inter-regional travel have made me consider a one-stop flight from Turin-Caselle Airport (TRN).
A two hour flight might also be safer than a two hour bus ride or a two hour train ride that transfers in the busy Milan central terminal. A study paid for by the International Air Transport Association (IATA), "Research Points to Low Risk for COVID-19 Transmission Inflight", finds that inflight COVID transmission is exceedingly rare. This is a pro-industry lobby, so the results should be read with a skeptical eye.
They compiled 44 cases out of 1.2 billion flying since the pandemic started. That's 1 case for every 27.3 million travelers
Even if 90% of infections were not counted, that would amount to 1 case for every 2.73 million travelers
Wherever I land, I plan to rent a car and drive down to Central Illinois to meet my parents. I will need to make sure I am tested and clear of the virus before I actually spend time with them. How this will work remains to be determined.
🛬 Airport 🇺🇸 → European Union 🇪🇺
I'm also concerned about returning to the European Union. I hold a residency permit, so I should have advantages over other Americans. But I find these travel bans a bit difficult to understand. They have many exceptions and it's always unclear how I fit into them.
With cases on the rise in the USA, it's possible that a new travel ban could be enforced. At the moment, the United States is currently grouped in List E of countries. The Italian Ministry offers an overview of what this means in English:
blockquote not implemented
On 7 October 2020, the Council of Ministers extended the nationwide state of emergency until 31 January 2021. The details will certainly change between now and the end of January.
With the numbers surging, it's difficult for me to relate to those who believe the virus is under control. But that's what many voters believe:
blockquote not implemented
Corriere della Sera's Milena Gabanelli does data-driven analysis for the Milan daily. Her work with Simona Ravizza looks at the standards set by the Istituto Superiore di Sanità (Italian National Institute of Health (ISS)) on masks. I'm particularly interested in washable/reusable masks.
To be certified by the ISS, these masks must meet 5 requirements (defined by the UNI EN 14683 standard): resistance to liquid splashes, breathability, bacterial filtration efficiency, microbial cleaning, and they cannot cause allergic reactions.
To meet the legally required levels of breathability, bacterial filtration efficiency, and microbial cleaning,
Washable masks must be washed every 8 hours at 30°C and able to withstand up to 20 washes (indicated by the manufacturer) before losing any of its effectiveness on the five dimensions above.
Washable masks with a pocket to insert a new activated carbon filter must abide by the same standards.
Look for the presence of the CE mark or the validation of the Higher Institute of Health on the packaging - the standard otherwise indicated as "EN 14683" on the packaging. These masks will offer a filtering capacity (i.e. protection from others) of either 95% (type I) to 98% (type II).
Protesters gathering in Turin's Piazza Castello were eventually dispersed by police firing tear gas into the crowd. The owners of small businesses seem especially aggrieved by the new restrictions.
Italy faces yet another difficult choice. The numbers in Piedmont look to be rising faster than they did earlier in the year. I hope this is true, in part, because of the rising number of tests. Stay healthy everyone.
Nexa talks are generally given on campus at the Polytechnic University. Unfortunately, COVID also made this an impossibility. I gave the talk online instead. This at least provisioned a decent recording of the talk (embedded below). For an overview and a few details on the finer points, please see my blog.
A New Government Directive For the Second Wave
Cases are once again rising in Piedmont and throughout Italy. In response, the Council of Ministers extended the state of emergency to January 31, 2021. They also introduced an obligation to wear masks outdoors and indoors (essentially anywhere other than in private homes) and extended the Immuni App's period of use.
When landing in Italy from Belgium, France, the Netherlands, the United Kingdom, the Czech Republic and Spain, travelers must take one of two precautions:
Upon boarding, travelers must present to their carrier a certification that they have undergone a molecular or antigenic test and received a negative response within 72 hours prior to entering Italy.
Take a molecular or antigenic test, to be carried out by means of a swab, when arriving at the Italian airport or within 48 hours of landing.
Most outbreaks are still linked to the home, but there is a sharp increase in the number of new cases where no epidemiological link was found.
(An outbreak is the identification of 2 or more positive cases linked to each other.)
CNN reporters Barbie Latza Nadeau and Livia Borghese sing Italy's praise as a new wave of infections are reported in Europe.
It's still too early to draw any definitive conclusions about Italy's lockdown. I can attest that the magnitude of the state's actions could be felt viscerally throughout Turin. The CNN report captures how restrictions were gradually lifted:
blockquote not implemented
I'll never forget the first dinner I had after the most intense part of the lockdown was lifted. We walked to Hui Wei Xiang and ordered a couple Crêpes Cinesi (aka Jianbing 煎饼). There was no eating indoors, so we walked to the Po River and watched people walk by. Up to that point, citizens were only allowed outdoors for a narrow set of purposes - always near their home and never in a group. It was the first night any of us could walk outside with our friends and family. This was indeed the "taste of freedom."
The authors continue to opine:
blockquote not implemented
I'm hoping for the best in Italy's choice to stay the course. Not only for my own sake, but as a model for other democracies that are struggling to balance the rights of citizens, economic realities, and the overall health of the population.
It looks like Italy is getting a lot of support from their neighbors:
How bad was the breakout in Italy? Out of nearly 10,000 Bergamo residents who had their blood tested between April 23 and June 3, 57% had antibodies, indicating they had come into contact with the virus and developed an immune response.
Apple and Google decided to bake an automated exposure notification service into their portable devices. The software will enable intra-device information exchange over Bluetooth while keeping each individual’s identity a secret.
Turin's Nexa Institute, a leading internet research body, has called into question the effectiveness and raised privacy concerns created by contact tracing apps.
My bottom line: the Apple/Google technology will be the most widely available technology intended to curb disease transmission while maintaining citizen privacy. If we are going to automate contact tracing in the West, this is how it will happen.
In the northern region of Lombardy, which includes the financial capital Milan and has been most ravaged by the disease, deaths were up 186 per cent in March from 2015-2019. They increased by 47per cent in neighbouring Piedmont to the west.
Looking at individual cities, the worst-hit was Bergamo, near Milan, where deaths were up 568 per cent in March compared with the 2015-2019 average. The nearby cities of Cremona and Lodi saw increases of 391 per cent and 370 per cent respectively. In Milan they rose 93 per cent.
In Rome, Italy's most populous city, which has been relatively lightly hit by COVID-19, overall fatalities were down 9 per cent from the previous five years. The Sicilian capital Palermo also posted a 9 per cent decline.
4.5 million workers are set to return to work today. Al Jazeera takes special note of the Piedmont region:
Entrepreneurs in the north have been preparing to ready their business premises for the reopening, while some resumed operations last week after being granted formal permission.
"We had to reopen, we didn't have a choice. I closed the activity having plenty of orders," said the owner of one engineering factory who asked to remain anonymous. In Piedmont's Alessandria, home to his factory, the case rate is still growing by 13.7 percent on a weekly basis. "If those orders [aren't fulfilled by] me," the owner said, "my clients would go somewhere else."
Around 80 people are employed in the factory, which was fully sanitised before its reopening. All machines and equipment are cleaned thoroughly at the end of each shift. All health protocols and guidelines provided by the government, in addition to further safety measures, have been implemented.
FCA (Fiat Chrysler Automotive) this week resumed van production at its Atessa plant in central Italy and some operations in other Italian plants, including preparatory works [for reopening on 4/May] at its Melfi facility for the final development of Jeep's new hybrid cars, and at Turin's Mirafiori plant for its new electric 500 small car.
Author of Arte povera: notes for a guerrilla war (1967), and Turin resident, Germano Celant dies from the corona virus (aged 80). The Arte Povera (Poor Art) movement sought to undermine established institutions and values. Much of its influence emanated from Turin.
The movement eventually became an influence. From Celant's obituary in The Art Newspaper: collectors’ support for his "guerrillas" was quickly won, confirming the apparent paradox by which the wealthy love to surround themselves in effigy with their opposites. By 1989 he had become a senior curator at the Guggenheim in New York City, an institution supported by a mix of old money and corporate sponsorship.
Celant saw this compromise as part of his vision. In 1988 he told Il Giornale dell'Arte: “A museum is a place of consumption; it must engage its consumers, stimulate and seduce them, so that they come again and again. I realize that this seems crudely industrial, but the survival of museums depends on an active, not a passive, destiny tied to the concept of an academy for a select few. Today the discourse is international."
New Prime Minister’s Decree For the Containment of Covid-19 Infection
Phase 2: Effective from May 4 and for the following two weeks.
Movements within the same Region for reasons of work, health, emergency or visit to relatives will be possible, nevertheless self-declaration is mandatory. The ban on group gathering is still in force. Access to public parks will be allowed by respecting the interpersonal distance.
As far as religious ceremonies are concerned, funerals will be allowed, attended by first and second degree relatives, with the obligation to wear a mask, and limited to a maximum of 15 people.
With regard to food service activities, in addition to home delivery, it will be possible to pick up the products from the venue, in compliance with the safety distance and with the prohibition of consumption inside or nearby.
Manufacturing, construction, real estate brokerage and wholesale trade will resume.
A two-bed intensive care unit within a shipping container, designed by Italian architects Carlo Ratti and Italo Rota, has been built at a hospital in Turin and is being used to treat patients fighting the coronavirus.
The pod, which contains two beds, has been installed at a temporary hospital built within the Officine Grandi Riparazioni complex in central Turin. The first patient was admitted earlier this week on 19 April.
A white collar, remote work strike occurred in Turin at Scai Finance on 23/April.
This may be the first such remote work strike in the history of Italy. I have long observed the history of Labor and have worked remotely throughout much of my career. Striking remotely would have seemed inconceivable just a few months ago. The shockwaves from this crisis will certainly resonate in unexpected ways.
A new study finds some interesting results from the earliest 14-day lockdown in Italy.
On the 21st of February 2020 a resident of the municipality of Vo, a small town near Padua, died of pneumonia due to SARS-CoV-2 infection. This was the first COVID-19 death detected in Italy since the emergence of SARS-CoV-2 in the Chinese city of Wuhan, Hubei province.
Scientists took surveys at two different points in the lockdown.
On the first survey, which was conducted around the time the town lockdown started, we found a prevalence of infection of 2.6%.
On the second survey, which was conducted at the end of the lockdown, we found a prevalence of 1.2%.
Notably, 43.2% of the confirmed SARS-CoV-2 infections detected across the two surveys were asymptomatic.
It didn't seem to matter if the distribution of infections were symptomatic or asymptomatic - viral load remained the same. In their words, most new infections in the second survey were infected in the community before the lockdown or from asymptomatic infections living in the same household.
Helen Ouyang of the New York Times covered the triage efforts by those in Turin and neighboring provinces. A group of doctors and bioethics experts attempted to draft a reasonable plan:
They include Marco Vergano, a 45-year-old I.C.U. doctor in Turin, in the neighboring province of Piedmont, who is also the chairman of the bioethics group of Italy’s society of intensivists (Siaarti). He’s working back-to-back shifts in the I.C.U., but he jumps online with the six other members of the task force.
[The group] strongly advise[d] against allocating precious resources, like ventilators and beds, on the traditional basis of first-come, first-served, which would reduce the number of lives a hospital could save.
Swift and fierce denunciation of the group and its recommendations follows the document’s release. “You cannot imagine to what extent we have to face harsh criticism,” Vergano says. [He] notes that most of the criticism has come from regions in Italy that have yet to be hit as hard as Lombardy.
The venue, which is commonly known as OGR and was founded by the CRT Foundation, will hold 100 hospital beds for patients recovering from COVID-19 who are in need of semi-intensive therapy, according to La Reppublica. Respirators and other equipment will be brought in for what is expected to be the next four months to relieve crowded intensive-care units at hospitals across Italy.
This seems to be advertorial content for Cisco, but it has some interesting details supplied by the mayor of Turin, Chiara Appendino:
They were able, in 3 weeks, to convert 40% of the City employees to remote work, something that had been evaluated just three months earlier and determined to be impossible. And when it came to setting up the emergency hospitals (the one they showcased had 3,00 beds), using partners, Cisco was able to help set up the networking and communications capabilities in 14 days and 3 hours with seven Cisco employees working with those partners.
Information is key to dealing with this pandemic. Setting up new information infrastructure on the fly is a unique challenge.
It seems masks and sanitizer have once again become available in the city:
What he and his colleagues have been witnessing in the “Isolation Ward” of the hospital over the past few weeks is no less than a nightmare. “We have 30 beds in our ward and all are almost continuously occupied. If a bed gets unoccupied, more often for a death than a discharge, it gets reoccupied within an hour or two,” [Madhu Hemegowda] tells the DH over phone from Turin.
Cocks co-founded The Art Newspaper and is currently in lockdown in Turin. She observes:
There is still one place where you can see real art: the doors of the churches are open, and they count as a place where you may go for “health reasons”.
This lockdown could be seen as the most extraordinary social experiment. Nothing like it has happened before, so I hope someone is keeping notes. Everything public is shut, from schools to bars to shops. No congregating is allowed anywhere for any reason. The church has obeyed the state and no public masses or other liturgies are being celebrated; I am awestruck at the thought that this must be for the first time since Christianity came to the peninsula in the days of Emperor Nero.
Prime Minister Giuseppe Conte announces the closure of all factories and production that is not absolutely essential.
The Military Arrives in Nearby Lombardy
And Chinese medical experts helping Italy deal with the crisis have said the restrictions imposed in Lombardy are "not strict enough."
The government has now agreed that the military can be used to help enforce the lockdown, the president of the Lombardy region, Attilio Fontana, told a news conference on Friday.
"(The request to use the army) has been accepted... and 114 soldiers will be on the ground throughout Lombardy... it is still too little, but it is positive," Fontana said. "Unfortunately we are not seeing a change of trend in the numbers, which are rising."
The soldiers had until now been deployed in the region to ensure general security in the streets.
In the Turin area, where I am based, Internet traffic doubled last week [...] Thierry Breton, the EU Commissioner for Internal Market, said that working from home and streaming put pressure on digital infrastructures.
Consequently, Breton asked Netflix to move to a lower video definition to reduce the bandwidth absorption, even creating a dedicated hashtag, #SwitchToStandard. Netflix, in response, announced it will reduce the bit rate in Europe for a month to reduce bandwidth usage by a fourth.
My sister contacted me, concerned with this excerpt from The Seattle Times: "The State Department on Thursday issued a new alert urging Americans not to travel abroad under any circumstances and to return home if they are already abroad unless they plan to remain overseas." Emphasis mine.
So I called the U.S. Consulate General in Milan today. They forwarded me to an emergency help center that is inundated with calls. I waited on hold for about 25 minutes.
The friendly individual on the other end suggested I enroll in the Smart Traveler Enrollment Program (STEP) today. The purpose of STEP "is to notify U.S. nationals in the event of a disaster, emergency or other crisis, and for evacuation coordination."
The State Department is currently issuing a Global Level 4 Health Advisory – Do Not Travel, which is not a travel ban for American citizens but a strong caution against unnecessary travel. The person on the phone said if I feel safe and have food and water then there is no immanent reason to leave.
Traveling at this point would make me more exposed to COVID-19.
[Nunzia Vallini] explained that the hospital in Brescia (near one of the hardest-hit regions for coronavirus infections) urgently needed valves (in the photo) for an intensive care device and that the supplier could not provide them in a short time. Running out of the valves would have been dramatic and some people might have lost their lives. [...] At the time of writing, 10 patients are accompanied in breathing by a machine that uses a 3D printed valve.
Italy's initial problem was that it simply couldn't identify the person who first brought the virus into the country, known as Patient Zero. That made tracing who that person had come into contact with impossible.
The first confirmed case, or Patient 1, came in a hospital in the northern region of Lombardy. Italian Prime Minister Giuseppe Conte admitted that the hospital there did not follow procedure and inadvertently helped the virus spread.
Comparing 🇮🇹 Italy and 🇰🇷 South Korea
Similar population size
Both confirmed suburban infections around the same time
Both reported an exponential increase of cases in the initial weeks.
Generally speaking, Italy has imposed a more restrictive lockdown than South Korea; South Korea has been testing and tracking more aggressively.
Today, South Korea records a minuscule death rate of less than 1%, according to World Health Organization figures, while Italy's reached over 14% on Friday [13-March], as the country reported another 250 deaths in just 24 hours. More than 1,200 people have died in Italy, which has more than 17,600 cases, officials there say. The global average death rate is currently between 3-4%.
Dewan suggests that testing and tracking might be the difference:
[Korea] has the resources to run about 15,000 diagnostic tests per day and has conducted more than 200,000 tests nationwide. Anyone referred to by a doctor or who has encountered an infected person gets that test for free.
While I am generally concerned about how all this citizen tracking may impact individual privacy in the future, the South Korean Foreign Minister Kang Kyung-wha shared a wonderful sentiment on the value of openness and international interdependence:
The spontaneous concerts and singing were happening all around Italy. The Independent, picked up a similar story in Siena. They highlighted a particularly interesting parallel with China:
Reminiscent of the chants from Wuhan high-rise apartments early in the epidemic there. Stay strong Italy. Praying for you guys.
Northern Italy, especially Lombardy and Piedmont, is the nation's manufacturing hub. Auto production has come to a near-complete halt.
For the second consecutive day very few vehicles are being produced in Italy. Only Ferrari is still building its supercars, but the staff at its plants in Maranello and Modena plants has been reduced to a minimum, the company said. Volkswagen Group's Lamborghini plant has halted production for nearly two weeks. Fiat Chrysler Automobiles' four assembly plants stopped regular production on Wednesday.
The measure provides for the suspension of further categories of services and commercial activities, apart from those involving the sale of food and basic needs, newsstands, tobacconists, pharmacies and parapharmacies. In any case, the interpersonal safety distance of one meter (three feet) must be guaranteed.
On Wednesday, Prime Minister Giuseppe Conte announced the latest step in a process that has progressively turned Italy into a fully quarantined country. [...] People who still go to the office are requested to prove the absolute necessity to do so by signing a certificate that must be submitted and vetted by the police. Transgressors face up to three months in jail and a fine. Going out for physical activity is permitted, provided it’s short and solitary. Schools and universities — which have been shut down since March 4 — will be closed at least until April 3, but the date will likely be extended.
Italy is aggressively testing for the virus, which could help explain why its total confirmed cases are higher than some other countries in Europe. On Tuesday, more than 60,000 tests had been performed, more than twice as many tests as the United Kingdom had done.
In contrast to most other countries, South Korea’s reports of new cases have begun to slow — at least for now. Unlike other countries with major outbreaks, South Korea, with a population of 50 million, has not outright restricted the movement of its citizens and has instead focused on aggressively monitoring for infections. [...] More than 235,000 people have been tested, and health officials carefully track down people who may have symptoms, testing more than 10,000 people each day.
Annalisa Malara tests positive for COVID-19 after being admitted to intensive care on 20-February. His activity between the 14th and the 20th likely spread it to hundreds of people including medical staff at the Codogno hospital.
Annalisa Malara, 38 years old, checks into an emergency room in Codogno in Lombardy with pneumonia. He had the flu since 14-February. ~ la Repubblica
The Importance of Open Science and Computational Notebooks
Open Science in the Pandemic
I pulled in the latest data on March 17th and immediately noticed something was wrong. The employee at the government's Dipartimento della Protezione Civile (Department of Civil Protection) had made a simple error inputting the dates. I cloned the data in the official repository, fixed the information, and requested they pull my (correct) data back into the official repository.
It wasn't a big deal, but it's a reminder of the importance of keeping source data open and in the the public. Thousands of people are auditing the data every day. In the West, our diversity is our strength.
On Computational Notebooks
Why a computational notebook on Nextjournal? Because the internet is more than a facsimile of 20th century technologies. It is larger than shareholder owned "public squares." It is a place for human authorship, not algorithmic curation.
Notebooks make it possible to take raw data and build a narrative with 21st century media. This notebook is re-runnable at any point in the future with the latest data, it is easily shared, and a starting point for conversation. Dr. Craig Spencer said it best: people need clear, concise evidence-based messaging. Notebooks are the perfect format for this effort.
If you'd like to know more about how exponential growth affects the spread of epidemics, this video is a great start. The video will help you understand why it's important to curb the spread of COVID-19 early.